The Consultation
Step Three: Obtaining A Comprehensive Case History
By W. Karl Parker, B.A., D.C., F.I.C.C., F.A.C.C.
e-mail: behapy@karlparkerseminars.com
Only when you have established rapport, is it time to gather
information and get specific details by conducting a comprehensive
case history examination. Begin the case history with your „setting
the stage¾ script ending it in a statement similar to the following:
"Mrs. Patient, I have studied the information on your patient
information form, and I want to know everything about your (chief
complaint). Show me exactly where it hurts¾ (or, "tell me about it.").
While making this statement, the doctor should lean forward, make
eye (according to the patient's preference), touch pain points (if
appropriate), and then set back in the chair ready to listen to the
patient answer your questions. Give the patient your full
concentration, listen intently, be a "big ear." Give the patient signs
of acknowledgment. Nod head in the affirmative to show the patient
you agree with what they are saying. Also, use verbal
acknowledgmentsã„I see,¾ „I understand,¾ "Yes," "No."
It is important to let patients purge themselves of their problem to
the point where they feel the doctor completely understands how
they feel. It is also important that the doctor stay in control and
not let the purging drift into areas of conversation that are
inconsequential or even unrelated the patient's problem. If the
patient starts to talk too much on these unrelated points, guide the
consultation by making statements and asking questions similar to
the following: "Just a moment, Mrs. Patient. This information is
very important and I would like to write it down." Then after making
a note of their last point, regain control by asking pertinent
questions.
Make extensive notes. Writing notes during the consultation shows
interest. The notes should include the patient's words as well as the
doctor's technical description. This information may be used for a
patient report as well as helpful in narrative reports contact and
expert witness testimony. Repeating the patient's own words in
describing their condition helps assure the patient that you
understand their problem.
As you gather information from the patient, keep in mind that there
are two important end results of data gathering:
1. Diagnostic --A good case history is very helpful in discovering
the cause of the problem and determine appropriate treatment.
2. Educational -- Well performed consultations are helpful in
leading patients to discover some of the principles of chiropractic.
Thee patients can learn that there must be a to cause inside their
body which allowed or perpetuated the health problem.
Survey information on all chief and chronic complaint(s) using the
following 11 points. A mnemonic system for these important points
has been developed for ease of use in the office and on office forms
such as those in your ChiroSource forms book. The most updated
"Patient Consultation" form we have provided you for use using the
Parker WayÅ does not list these initials, but all these points are
covered in a more easily guided manner leaving less for you to learn
and memorize. The 11 points below will serve to help you fully
understand the most pertinent data to gather from your patients
during your consultations.
1. P.O.P.- Position Of Pain.
a. Precisely note the patient's symptoms.
1) Exact location.
2) Type of symptom: constant or intermittent, ache or pain, dull or
sharp, shooting or steady, numbness or tingling, tense or tight, weak
or strong.
3) Other information regarding the symptoms: How long does it
last? How often does it occur? Is it becoming worse, improving or
remaining the same? Is there anything that precipitates it (brings
it on)?
4) Ask additional questions to show your awareness of the
problem and to explore differential diagnosis and determine the
extent of the condition.
b. Besides writing a word description, also use a red pen and note
the information clearly on the human figure of the consultation
form.
2. D.O.C. Duration Of Condition.
a. It is important to find the true beginning of not only the
symptoms but the cause of the present condition. Ask the patient
when they first noticed any aspect of the problem
b. Dig for chronicity; establish the cause which usually occurs
long before symptoms by asking questions similar to the following:
"Have you ever had this or a similar condition before? Think hard as
a child, a teenager?" "How long has it been since you really felt
good?" "Do you have muscle spasms or twitches? Where?" Etc.
c. If patient is unaware of any chronic history of their
condition, ask questions related to symptoms that are common in
that area. For example, a patient with headaches often has sinus,
hay fever, etc., but never thinks of chiropractic. Also, check the
Patient Case History form the patient completed for related
symptoms.
3. N.L.W.- Normal Living and Working.
a. Search for normal daily activities that affect the patient's
condition, both positively and negatively.
b. Note inability to perform normal functions.
4. A.E.P.- Adverse Environmental Possibilities.
a. Determine whether or not the patient believes that
something in the environment contributes to his or her problem.
b. If patients reveal their belief that the environment ("Pollen
caused my allergies") or the symptom ("I believe I have bursitis") is
the cause of their problem, relate the patient's belief to being
actually an aggravating influence to the true cause, if true.
5. H.P.- Hereditary Possibilities.
a. Determine any direct hereditary effects related to the
patient's condition.
b. Determine any relationship problem to "acquired-by-
lifestyle" traits that might affect this person's condition.
c. This information is best obtained by having the patient complete
a "Family Health History Record" form. After inquiring into this
area, tell the patient you need this form completed and returned on
the next visit. The CA can present the form at the conclusion of the
visit.
6. P.S.F.A.- Previous Surgery, Falls and Accidents.
a. Note all past traumas that might have caused, precipitated or
affected their spinal condition.
b. Determine relationship between patient's traumas and the
duration of condition.
c. Note all previous surgeries.
7. N.O.D.- Names Of Doctors.
a. Note names of all doctors seen for the present condition or any
similar condition as well as the name of the patient's usual family
doctor.
b. Determine dates of last visit with previous doctors.
c. Never make derogatory remarks about another doctor. Instead
use hearsay praise: "I understand Dr. Jackson has a good reputation."
Remember, you never build yourself up by putting someone else
down. Also, when you praise other doctors who have not helped the
patient, consider what it makes You...when You do!
d. Determine if patient has seen another doctor for anything,
recently. Other problems not presently active may give information
about present condition.
8. P.D.- Previous Diagnosis.
a. Determine diagnosis of each doctor seen for the patient's
present condition.
b. If the previous diagnosis is merely a name for the symptoms of a
condition, (i.e., bursitis) then probe to determine what the previous
doctor's opinion is of the cause of that condition. Of course, there
usually isn't any, except possibly environmental, and the patient can
subtlety be made aware of that fact.
9. F.T.- Former Treatment.
a. Note all types of treatments performed or recommended by other
doctors seen for this condition as well as the effects of that
treatment.
b. Determine if patient has done anything else, even home
remedies which they feel have been effective or ineffective.
c. If patient has had previous chiropractic care, whether it was for
this condition or not, note the types of treatment administered and
the results.
d. Note any medication or nutritional supplementation that the
patient may be presently taking, whether or not it is for this
condition. Be sure to obtain exact names, dosages, and the reason
for taking the medication or supplementation.
10. L.O.T.- Length Of Treatment.
Note the length of the treatments previously administered.
11. Other information.
a. Determine why patient quit previous doctors.
b. Determine former examinations performed by previous doctors in
order to make their diagnosis and determine their treatment
program.
c. Ask patient about other health problems.
d. Make a note of patients' fears regarding their condition and
evaluate the case to alleviate those fears. Add this information to
your report of findings and also implant concept of chiropractic
prevention methods.
e. Give the patient a last opportunity to tell you anything else about
their condition before concluding the consultation.
The importance of a comprehensive consultation and case history
cannot be over emphasized. Following the 11 point case history
format will guide you in getting the necessary information to help
you with your diagnosis and treatment program. This format should
be followed for each separate condition. Each individual patient is
different and the 11 point case history is just a guideline. You may
need to ask many questions of an individual patient that are not
specifically covered in the 11 points.